Subjective data - correct answer ✔✔includes patient's explanation of the problem and perception of
pain
Objective clinical evidence - correct answer ✔✔contains information such as the physical exam, lab
results, radiological information
POMR - correct answer ✔✔divides records into four sections
-database(pt's chief complaint)
-problem
-treatment
-progress
Paper-based records are prepared for filing and storage by performing 5 steps: - correct answer ✔✔-
conditioning
-releasing
-indexing and coding
-sorting
-filing
Conditioning - correct answer ✔✔removing any attached metal such as pins, staples, and paper clips
, Release - correct answer ✔✔the release of a document is performed by making a mark- such as a stamp
or the medical assistant's initials- on the medical record to show that the paperwork is ready for filing
Indexing and coding - correct answer ✔✔consists of organizing paperwork added to the file
-every document added to the file should be added to the medical record faced up and should have pt's
name and date on each form
3 filing methods - correct answer ✔✔-alphabetical by name (last name listed first)
-numerical (by number that was assigned to the patient)
-or by subject (used to organize info rather than pt medical records)
terminal digit filing system - correct answer ✔✔the last group of numbers are ranked as the primary
numbers for filing
-ex: if the record is 223456, the ID can be divided into 22-34-56 where 56 serves as the terminal digits
and directs filing
-facilities with large find the terminal digit filing system to be the most effective instead of the
alphabetical system bc you can have many patients with the same last name
-alphabetical color coding and numeric color coding
pt's social history - correct answer ✔✔includes use of tobacco, alcohol, and illegal drugs
Informed consent - correct answer ✔✔-prepare the consent form, present it to the physician to explain
the information to the patient.
-the medical assistant wilol witness the signature of the patient, BUT MUST NOT BE THE INDIVIDUAL
THAT EXPLAINS THE CONSENT FORM TO THE PT BC THIS COULD BE CONSIDERED PRACTICING MEDICINE
WITHOUT A LICENSE.
-make a copy of the consent form and file their original copy
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